a PAEDIATRIC CASE STUDY ASSESSMENT
Introduction
The following case study highlights a number of concerns that many in the optometric world currently have in relation to paediatrics namely the development and progression of myopia, treatment to halt said progression
This case study aims to educate and dispel misconceptions some parents have on this functional impairment.
The following case study is interesting as it highlights a number of issues that are ??? (topical)
PX ID: 19802
D.O.B 30/03/2009
A 9 year old schoolboy, accompanied by his mother, presented for an eye exam in mid October. The reason for the visit was a routine check up. There were no previous records on file.
Last eye exam was 1 month previous and first time spectacles for myopia were prescribed at that exam. Full case history revealed no ?? of significance significant
and no concerns from the parent
The last eye exam was 1 month ago and it was at this visit that the child was first prescribed glasses for myopia. The child was struggling to see the blackboard at school. However, no glasses were brought to this appointment as they forgot to bring them. It was at this point that the mother revealed that she does not like her son wearing glasses and does not allow him to wear them. Does not wear glasses often. The child reported that he sometimes experiences headaches and on further questioning he explained that they happen at the front of his head when he is tired at the end of a school day. He isn’t given any analgesics to relieve symptoms as they go away on their own.
This child was of Chinese background with his mother being Chinese also. His mother had laser eye surgery for myopia in Hong Kong many years ago and as a result does not wear any spectacle correction now. There are no other family members who wear glasses. Patient reported good general health. No history of eye disease in the family and no history of injury, infection or surgeries. Patient never had to wear a patch
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The clinical findings were as follows:
TABLE FOR
B, H, P , M
UV, RETS,
CT, CV, TNO
EXTERNAL AND OPHY
Brückner: No asymmetry or abnormally bright reflexes. Reflexes brighter on bottom suggestive of myopia. No columnar reflexes
Hirschberg: No difference or displacement in corneal reflexes
Pupils: Round and regular, no RAPD
Motility: SAFE
Chart: Crowded LogMar Chart
Unaided Vision:
Binocularly 6/19
RE 6/19
LE 6/24
VISION DO A TABLE!!!!!
External Examination: lids, lashes, lens, cornea, conjunctiva and other adnexa appear healthy
Indirect Ophthalmoscopy:
CD Ratio 0.4 R and L
Moderate cupping depth in both eyes
Disc margins well defined
ISNT applied
No sign of myopic fundus
Macula and Periphery flat and healthy
Fundus pictures taken
All ocular slit lamp and ophthalmoscopy findings were within expected ranges.
Stereopsis: TNO, 60 seconds of arc
Colour Vision: HRR carried out Binocularly- All plates passed
Cover Test: Orthophoric at Distance and Near
As there was no previous Rx on file a cycloplegic refraction was carried out for a baseline Rx (paper)
1 drop Proxymetacaine Hydrochloride 0.5% w/v followed by 1 drop Cyclopentolate Hydrochloride 1% w/v
Retinoscopy
Mohindra
Dynamic
Static
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PAPERS AND RESEARCH LIT REVIEW
In the literature, myopia is considered a significant ophthalmic concern [1. moon and shin]. The prevalence and degree of myopia has been rapidly increasing over time [2][3]
The Ireland Eye Study (IES) which is the first study to report on refractive error prevalence and visual impairment in schoolchildren living in Ireland
variation and a dramatic increase in the prevalence of myopia from the late 20th century onwards.8 – This is particularly evident in East Asia, where myopia is a growing health issue with a prevalence of 80%–90% in school leavers.9 Myopia prevalence is clearly influ- enced by ethnicity, but environment has also been demonstrated to play a significant role in the onset and progression of the condition.
The proportion of participants who presented wearing spectacles was 8.8% of participants aged 6–7 years old and 13.8% of those aged 12–13 years old; however, of those who reported that they had a current spectacle correction, a proportion did not have their spectacles at school (3.9% of participants aged 6–7 years old and 10.7% of those aged 12–13 years old). The refractive profile of participants who did not have their spectacles at school was mainly hyperopic (53.6%) in the younger cohort and astigmatic (44.8%) or hyperopic (32.3%) in the older age cohort (table 4).
IES the myopia prevalence in Ireland schoolchildren (6–7 years 3.3%, 12–13 years 19.9%) for the period June 2016–January 2018 was comparable with the myopia prevalence in Ireland schoolchildren (6–7 years 3.3%, 12–13 years 19.9%) for the period June 2016–January 2018 was comparable with that reported in the UK Northern Ireland Childhood Errors of Refraction (NICER) study (6–7 years 2.8%, 12–13 years 17.7%), Aston Eye Study (AES) (6–7 years 5.7%, 12–13 years 18.6%),18 22 Poland (7 years 4.0%, 12 years 14.4%)24 and Australia (6 years 1.6%, 12 years 12.8%),25 26 and significantly lower than that reported in China (5 years 5.7%, 15 years 78.4%).27 In line with the majority of other studies, a significantly higher myopia prevalence was found in children aged 12–13 years old than those aged 6–7 years old.
Similar to Zhang et al,31 the ‘See well to learn well’ project reported inac- curate spectacle prescriptions to be common and recommended annual refractions to address this issue.
Having 1 parent with myopia, irrespective of ethnicity, leads to a 20-25% increased chance of the child being myopic and having 2 myopic parents leads to a 30-40% increase (MUTTI 1995)
YANG ET AL – Chinese populations have the highest prevalence of myopia in the world and may be one of the ethnicities which are the most susceptible to myopia (Fan et al., 2004; He et al., 2004; Lin et al., 2004). It is of interest that those Chinese youngsters who were born and live overseas, still have much higher occurrence of myopia than the native population, even though they have the same educational and cultural environment (Wu et al., 2001; Kleinstein et al., 2003; Goh et al., 2005).
MIMOUNI ET AL Cycloplegia is often more difficult to achieve in younger subjects with darker irises, most probably due to the sequestration of cycloplegic agents by the iris pigment [13, 14]. Therefore, the use of 1 % cyclopentolate has been recommended in order to achieve full cycloplegia, as was performed here [15].
Cycloplegic refraction was carried out on this child to rule out pseudo myopia. A study by Mimoumi et al states that the accuracy of refraction is affected by accommodation which can lead to a myopic shift. Cycolplegic refraction should therefore be carried out in children as their accommodation is active and to guarantee accurate refraction (5)(5)
WHO TO CYCLO: IN NOTES REFERENCE
squinting encourages with the rule astigmatism
0.01% atropine drops compounded by pharmacy
In the latest network Meta-analysis to determine the effectiveness of different interventions in slowing the progression of myopia in children, Huang et al[12] reported that the most effective intervention that showed a significant reduction in myopia progression involved pharmacological agents such as atropine and pirenzepine. Orthokeratology and peripheral defocus modifying contact lenses showed moderate effects, and progressive addition spectacle lenses showed minimal effects[12]. Atropine eye drops are therefore considered the most effective treatment for inhibiting myopia progression. Atropine is a nonselective muscarinic antagonist. MOON ET AL
use this study 285 children
YANG – Although we also found that near esophoric myopes benefitted from PALs, compared with SV lenses, we did not find near lag a differential treatment factor in this study. This indicates that those Chinese children with a large near lag do not necessarily have a slower progression rate than those with a low near lag when wearing PALs. A very recent study reported differences in near lag as a function of ethnicity (Mutti et al., 2006). One possible explanation could be that near lag might play a weaker role during myopia development in Chinese than in Caucasians, which remains to be confirmed.
META ANALYSIS:
advice for parents: time outdoors screen time etc etc
Research is showing that children who spend more time outdoors are less likely to become myopic, irrespective of how much near work they do, or whether their parents are
myopic. (amanda)
IES: The highest prevalence of myopia is children spending more than 4hrs per day on screens
Because pathologic myopia may result in complications such as choroidal neovascularization, retinal detachment, and glaucoma[1-3] – moon and shin
In addition, a meta-analysis of 11 cross- 100 sectional studies has shown an increased risk of open angle glau- 101 coma with both low and high myopia, with odds ratios of 1.77 and 102 1.88 respectively (Marcus et al., 2011). Myopia also poses an 103 increased risk of retinal detachment which increases with the 104 severity of myopia (Chou et al., 2007), and there are associations 105 between myopia and cataract (Leske et al., 1991), although the 106 causal relationship is not clear. Serious complications due to retinal 107 and choroidal pathologies associated with myopia also increase 108
with myopia severity (Vongphanit et al., 2002),
amanda french – decreasing the amount of near work
In
136 children, there is also an almost universal pattern of increasing
137 myopia prevalence with years of schooling, and increased myopia
138 with children with higher examination results (Saw et al., 2007)
139 and those in academically selective schools or streams (Quek et al.,
140 2004).
C/D and cupping depth:
ERKKILA T h e ophthalmoscopic features of the optic discs were studied in a series of 41 1 non-selected school children representing four age groups from 7 to 15 years.
WHAT VISION SHOULD BE: LECTURE NOTES
TNO AND CV: IN NOTES FOR NORMAL VALUES
MANAGEMENT
Unfortunately, the patient’s mother rushed the end of the appointment. Drops had already been instilled
The subjective refraction was sadly very rushed which made it very difficult to attain the most definite end prescription.
Final Rx
RE: -1.50 VA 6/7.6
LE: -2.00/-0.50X10 VA 6/7.6
As the child’s glasses were not present at the appointment it was impossible to know if there was any change in prescription. The mother was strongly advised to bring the glasses in when convenient so that a discussion regarding any change in prescription in addition to the importance of her child wearing spectacle correction could take place.
The suitable recall for this child is 12/12 unless there are any concerns in the meantime.
myopia control in future with ortho k or MiSight lenses
MISIGHT SPANISH STUDY ALICIA AND ALSO ORTHO K
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References
[1]
[2] Rose KA, Morgan IG, Smith W, Mitchell P. High heritability of myopia does not preclude rapid changes in prevalence. Clin Experiment Ophthalmol 2002;30:168–72.
3. Holden BA, Fricke TR, Wilson DA, et al. Global prevalence of myopia and high myopia and temporal trends from 2000 through 2050. Ophthalmology 2016;123:1036–42. y in here…